Jonathan S. Comer

National Trends in Child and Adolescent Psychotropic Polypharmacy in Office-Based Practice, 1996-2007

OBJECTIVE To examine patterns and recent trends in multiclass psychotropic treatment among youth visits to office-based physicians in the United States. METHOD Annual data from the 1996-2007 National Ambulatory Medical Care Surveys were analyzed to examine patterns and trends in multiclass psychotropic treatment within a nationally representative sample of 3,466 child and adolescent visits to office-based physicians in which a psychotropic medication was prescribed. RESULTS There was an increase in the percentage of child visits in which psychotropic medications were prescribed that included at least two psychotropic classes. Across the 12 year period, multiclass psychotropic treatment rose from 14.3% of child psychotropic visits (1996-1999) to 20.2% (2004-2007) (adjusted odds ratio [AOR] = 1.89, 95% confidence interval [CI] = 1.22-2.94, p < .01). Among medical visits in which a current mental disorder was diagnosed, the percentage with multiclass psychotropic treatment increased from 22.2% (1996-1999) to 32.2% (2004-2007) (AOR = 2.23, 95% CI = 1.42-3.52, p < .001). Over time, there were significant increases in multiclass psychotropic visits in which ADHD medications, antidepressants, or antipsychotics were prescribed, and a decrease in those visits in which mood stabilizers were prescribed. There were also specific increases in co-prescription of ADHD medications and antipsychotic medications (AOR = 6.22, 95% CI = 2.82-13.70, p < .001) and co-prescription of antidepressant and antipsychotic medications (AOR = 5.77, 95% CI = 2.88-11.60, p < .001). CONCLUSIONS Although little is known about the safety and efficacy of regimens that involve concomitant use of two or more psychotropic agents for children and adolescents, multiclass psychotropic pharmacy is becoming increasingly common in outpatient practice.

Disasters and Youth: A Meta-Analytic Examination of Posttraumatic Stress

OBJECTIVE Meta-analyze the literature on posttraumatic stress (PTS) symptoms in youths post-disaster. METHOD Meta-analytic synthesis of the literature (k = 96 studies; Ntotal = 74,154) summarizing the magnitude of associations between disasters and youth PTS, and key factors associated with variations in the magnitude of these associations. We included peer-reviewed studies published prior to 1/1/2009 that quantitatively examined youth PTS (≤ 18 years at event) after a distinct and identifiable disaster. RESULTS Despite variability across studies, disasters had a significant effect on youth PTS (small-to-medium magnitude; rpooled = .19, SEr = .03; d = 0.4). Female gender (rpooled = .14), higher death toll (disasters of death toll ≤ 25: rpooled = .09; vs. disasters with ≥ 1,000 deaths: rpooled = .22), child proximity (rpooled = .33), personal loss (rpooled = .16), perceived threat (rpooled = .34), and distress (rpooled = .38) at time of event were each associated with increased PTS. Studies conducted within 1 year post-disaster, studies that used established measures, and studies that relied on child-report data identified a significant effect. CONCLUSION Youths are vulnerable to appreciable PTS after disaster, with pre-existing child characteristics, aspects of the disaster experience, and study methodology each associated with variations in the effect magnitude. Findings underscore the importance of measurement considerations in post-disaster research. Areas in need of research include the long-term impact of disasters, disaster-related media exposure, prior trauma and psychopathology, social support, ethnicity/race, prejudice, parental psychopathology, and the effects of disasters in developing regions of the world. Policy and clinical implications are discussed.

Health-related quality of life across the anxiety disorders: results from the national epidemiologic survey on alcohol and related conditions (NESARC).

OBJECTIVE Although clinical studies have documented that specific anxiety disorders are associated with impaired psychosocial functioning, little is known regarding their comparative effects on health-related quality of life within a general population. The current analysis compares health-related quality of life in a US community-dwelling sample of adults with DSM-IV social anxiety disorder, generalized anxiety disorders (GAD), panic disorder, and specific phobia. METHOD A face-to-face survey of a US nationally representative sample of over 43,000 adults aged 18 years and older residing in households and group quarters was conducted. Prevalence of DSM-IV anxiety disorders and relative associations with health-related quality of life indicators were examined. The survey was conducted from 2001 to 2002. RESULTS Roughly 9.8% of respondents met diagnostic criteria for at least 1 of 4 twelve-month DSM-IV anxiety disorders which, relative to the non-anxiety-disordered general population, were each associated with lower personal income, increased rates of 12-month physical conditions, and greater numbers of Axis I and Axis II DSM-IV psychiatric conditions. After adjusting for sociodemographic and clinical correlates, including other anxiety disorders, GAD was associated with significant decrements in the SF-12 mental component summary score. In similar models, GAD and, to a lesser extent, panic disorder were significantly associated with impairment in social functioning, role emotional, and mental health SF subscales. CONCLUSIONS GAD, followed by panic disorder, appears to exact significant and independent tolls on health-related quality of life. Results underscore the importance of prompt and accurate clinical identification and improving access to effective interventions for these disorders.

Emotion-focused cognitive-behavioral therapy for anxious youth: A multiple-baseline evaluation

Examined the efficacy of an Emotion-focused Cognitive-Behavioral Therapy (ECBT) for six anxious youths ages 7–13 years. All participants had a principal anxiety disorder (generalized anxiety disorder, separation anxiety disorder, or social phobia) based on the Anxiety Disorder Interview Schedule for Children—Child and Parent versions. Children and parents reported on anxious symptomatology using the Multidimensional Anxiety Scale for Children (MASC). To assess emotion-related competencies, children were administered the Kusche Affective Interview—Revised and children and parents completed the Emotion Expression Scale for Children (EESC) and Emotion Regulation Checklist (ERC), respectively. Cases began treatment after baselines of 0, 2, or 3 weeks. At posttreatment, the majority of children demonstrated improvements in anxious symptomatology, emotion understanding and regulation skills, and overall functioning. Such improvements in emotion-related skills, in addition to anxiety, are significant given that emotional competence is a crucial component in childrens adaptive social functioning and psychological adjustment. These findings provide initial support for ECBT.

The occasional case against broad dissemination and implementation: retaining a role for specialty care in the delivery of psychological treatments.

Mental illness imposes a staggering public health burden in the United States. Although the past 40 years have witnessed tremendous advances in the identification of evidence-based practices (EBPs) in psychological treatments, gaps persist between treatment in experimental settings and services available in the community. In response, considerable attention and large financial commitments have focused in recent years on broad dissemination and implementation efforts designed to improve the quality of psychological services delivered by a variety of generalist practitioners across practice settings. Increasingly, under the influence of the Patient Protection and Affordable Care Act, it is envisioned that these generalists will practice in integrated primary care settings. These advances hold enormous potential, and yet, given the tremendous diversity of mental health problems and human suffering, broad dissemination and implementation efforts to generalists alone may not be sufficient to adequately address the burden of mental illness. Some EBPs may prove too complex for universal dissemination, and the time and expense required for quality dissemination and implementation preclude large-scale training in the treatment of low base rate disorders. As dissemination and implementation efforts work to ensure a quality generalist mental health care workforce, herein we highlight the vital need for available specialty care in the delivery of psychological treatments. Given traditional barriers that interfere with the accessibility of specialty care, we propose the transformative potential of a specialty behavioral telehealth care workforce, transacting with the generalist practitioner workforce to collectively ensure the highest quality and timely delivery of needed treatments to affected individuals.

Parental Responses to Positive and Negative Emotions in Anxious and Nonanxious Children

This study examined the role of multiple childrens emotions and parental anxiety during parent–child interactions of anxiety disordered (AD) and nonanxious (NA) children ages 7 to 13 years. Families (mother, father, child) each discussed three recent and real separate situations in which the child experienced anxiety, anger, and happiness. Results revealed significant differences in behavior between parents of AD and NA children. Maternal behavior, but not paternal behavior, was related to the emotion the child was experiencing. Mothers of AD children displayed greater intrusive involvement than mothers of NA children in those situations in which the child was experiencing negative affect. A significant interaction was evident between maternal anxiety disorder and emotion, whereby anxious mothers were more intrusive in situations involving anxiety and anger (compared to positive emotion situations), whereas nonanxious mothers were more intrusive only during situations involving anger.

In-session exposure tasks and therapeutic alliance across the treatment of childhood anxiety disorders.

The study examined the shape of therapeutic alliance using latent growth curve modeling and data from multiple informants (therapist, child, mother, father). Children (n = 86) with anxiety disorders were randomized to family-based cognitive-behavioral treatment (FCBT; N = 47) with exposure tasks or to family education, support, and attention (FESA; N = 39). Children in FCBT engaged in exposure tasks in Sessions 9-16, whereas FESA participants did not. Alliance growth curves of FCBT and FESA youths were compared to examine the impact of exposure tasks on the shape of the alliance (between-subjects). Within FCBT, the shape of alliance prior to exposure tasks was compared with the shape of alliance following exposure tasks (within-subjects). Therapist, child, mother, and father alliance ratings indicated significant growth in the alliance across treatment sessions. Initial alliance growth was steep and subsequently slowed over time, regardless of the use of exposure tasks. Data did not indicate a rupture in the therapeutic alliance following the introduction of in-session exposures. Results are discussed in relation to the processes, mediators, and ingredients of efficacious interventions as well as in terms of the dissemination of empirically supported treatments.

Internet-Delivered, Family-Based Treatment for Early-Onset OCD: A Preliminary Case Series

Given the burdens of early-onset obsessive-compulsive disorder (OCD), limitations in the broad availability and accessibility of evidence-based care for affected youth present serious public health concerns. The growing potential for technological innovations to transform care for the most traditionally remote and underserved families holds enormous promise. This article presents the rationale, key considerations, and a preliminary case series for a promising behavioral telehealth innovation in the evidence-based treatment of early-onset OCD. We developed an Internet-based format for the delivery of family-based treatment for early-onset OCD directly to families in their homes, regardless of their geographic proximity to a mental health facility. Videoteleconferencing (VTC) methods were used to deliver real-time cognitive-behavioral therapy centering on exposure and response prevention to affected families. Participants in the preliminary case series included 5 children between the ages of 4 and 8 (M Age = 6.5) who received the Internet-delivered treatment format. All youth completed a full treatment course, all showed OCD symptom improvements and global severity improvements from pre- to posttreatment, all showed at least partial diagnostic response, and 60% no longer met diagnostic criteria for OCD at posttreatment. No participants got worse, and all mothers characterized the quality of services received as “excellent.” The present work adds to a growing literature supporting the potential of VTC and related computer technology for meaningfully expanding the reach of supported treatments for OCD and lays the foundation for subsequent controlled evaluations to evaluate matters of efficacy and engagement relative to standard in-office evidence-based care.

Changes in Emotion Regulation Following Cognitive-Behavioral Therapy for Anxious Youth

This study examined emotion-related functioning following cognitive-behavioral therapy (CBT) with 37 youth with anxiety disorders (22 boys, 15 girls) ranging in age from 7 to 15 with a principal diagnosis of generalized anxiety disorder (n = 27), separation anxiety disorder (n = 12), and/or social phobia (n = 13). Treated youth exhibited a reduction in anxiety and increased anxiety self-efficacy and emotional awareness at posttreatment. Treated youth also demonstrated improved coping and less emotional dysregulation with worry but not with anger or sadness. The results suggest that the gains made in worry regulation do not generalize to other emotions that are not specifically targeted within the CBT protocol.

National trends in the antipsychotic treatment of psychiatric outpatients with anxiety disorders.

OBJECTIVE The purpose of the present study was to examine patterns and recent trends in the antipsychotic medication treatment of anxiety disorders among visits to office-based psychiatrists in the United States. METHOD Annual data from the 1996-2007 National Ambulatory Medical Care Survey were analyzed to examine the patterns and trends in antipsychotic medication treatment within a nationally representative sample of 4,166 visits to office-based psychiatrists in which an anxiety disorder was diagnosed. RESULTS Across the 12-year period, antipsychotic prescriptions in visits for anxiety disorders increased from 10.6% (1996-1999) to 21.3% (2004-2007). Over the study period, the largest increase in antipsychotic prescribing occurred among new patient visits. Antipsychotic prescribing also significantly increased among privately insured visits and visits in which neither antidepressants nor sedative/hypnotics were prescribed. Among the common anxiety disorder diagnoses, the largest increase in antipsychotic medication treatment was observed in visits for panic disorder. Antipsychotic prescribing rose from 6.9% (1996-1999) to 14.5% (2004-2007) among visits for anxiety disorders in which there were no co-occurring diagnoses with an indication approved by the Food and Drug Administration for antipsychotic medications. CONCLUSIONS Although little is known about their effectiveness for anxiety disorders, antipsychotic medications are becoming increasingly prescribed to psychiatric outpatients with these disorders.